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4', <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW.s Ov.Of lehd <br />EXPIRES 1 YEAR FROM UATE ISSUED <br />, <br />r <br />CITY/ZIPG <br />CA <br />JOB ADDRESS <br />CROSS STREET r `� ` <br />f�1 t <br />N �y ■d <br />PCEL SIZE) O LAND USE APPLICATION # <br />APb TOAR <br />OWNER NAME ]C+`� Cl'rS <br />6 <br />PHONE <br />Qp'a e -91r <br />OWNER ADDRESS �� / <br />- Y -o— Yr,S CITYlSTATE/ZIP <br />/4' <br />- <br />6-Q - ?-f <br />CONTRACTOR �h\ 19� \ It. <br />\I Nc-. .M <br />o <br />PHONE <br />CONTRACTOR ADDRESS S' <br />t— 11Ori <br />K.•1Q CITY/STATE/ZIP <br />+ <br />1 y, l" C,� �q• -3�O <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />ADDRESS <br />X57 C-6' D-09 Other <br />PARTY: OWNER XONTI <br />CrrY/STATE/ZIP <br />NUMBER 'A5 q ` EXPIRATION DATE 'r /a'1 <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Alnigation/Agricultural Industnal Water Quality Monitoring Soil Sampling/Characierization <br />Public Water System <br />If different from Owner Waler System Name Contact Name nr Phone Number <br />TYPE OF WORK ' New Well h Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) a o! bo—gs Geotechnical a of borngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair _ - Raise Well Casng <br />Drilling Method hMud F-'- Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth _)so ft Excavation I in diameter Open Bottom � Gravel Pack/Gravel Size —i -j, in diameter <br />Conductor Casing N lit, in diameter I Conductor Casing Depth A I f` ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad 5"IN Db Steel > ,Plastic Stainless Steel Other <br />Grout Seal D It Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack m/x/7 gal water <br />Bentonite (20 % solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal DimensionsWidth ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set If Standing Water Level " I <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />fAK7,1blti'1 Jq g0UP ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953.7697 <br />w <br />D <br />0 <br />m <br />N <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By DateJ� 2� <br />Pump Inspection By Date <br />Soil BoringInnspectior) By Date <br />COMMENTS I d1P 1 ki bE e,10Y Oi- file oclSlnti �,��,� irlit t 1 -If c'le <br />j, " la,,, j,h} In.let Cee I -j4 l e Lyt rtc, Ill^.r i? r J 4 t-CWV-`''' <br />Area •} % Employee ID# DA <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />pir-Y I. , n%tnn ,.1.. 4, i I, r,, l7u At r:;L)i_ I—< <br />PE Sc <br />e <br />CodInfo <br />Received\ Oh Amount pate Permit/ Invoice # Well ID# <br />�/son if, Remitted rvice Re oast # <br />E4D 43-06 6:11'2019 <br />NELL /PUMP PERMIT <br />HENT <br />EINE® <br />03 2021 <br />)UIN COUNTY <br />)NMENTAL <br />)EPARTMENT <br />